Op. Dr. Niyazi Emre Turgut - In Vitro Fertilization ( IVF )

Classic IVF (In Vitro Fertilization)

Classic IVF is the original method. Although its application has decreased over time, there are still centers that use it as the main method. In traditional IVF, women's eggs are retrieved during the egg collection procedure and male sperm are released into the same environment and kept together for several hours. The goal is to allow the egg to be fertilized by the sperm naturally in the same way it happens in our bodies. The microinjection of a sperm into an egg by an embryologist is not performed. Ideally, this method should be applied in cases with a large number of eggs and motile sperms.

ICSI

Intracytoplasmic sperm injection (ICSI) is an IVF procedure in which a single sperm selected under a microscope is injected directly into the egg. A tiny needle, called a micropipette, is used to perform this delicate procedure. In our practice, ICSI is the routine procedure:

For couples where the egg number is low;
For cases with sperm disfigurement, low number, and low motility;
For couples with fertilization-related failures in earlier IVF trials;
When preimplantation genetic testing (PGT) is planned;

IMSI

Intracytoplasmic Morphologically Selected Moving Sperm Injection (IMSI) is the preferred method in cases with severe disfigurement in sperm. The most important advantage of this technique is using significantly higher microscopic magnification (more than x6000 times) to select the best sperm cells. This prevents the use of abnormally structured sperm that can negatively affect the fertilization process.

Microchip

Microchip (microfluidic chip-based sperm sorting) is a method developed to enable safer and better sperm selection in cases where there are issues with sperm motility and disfigurement. Sperm quality plays a major role in embryo quality and development. The density-gradient centrifugation method is used in classic IVF. This method separates sperm based on motility, size, and density. After separation, the sperm cells are selected under a microscope with a classic magnification of 200 times or more than 6000 times magnification with an advanced microscope, the selected sperm cells are then injected into the eggs. The use of a microchip allows us to select more motile and healthier sperm cells. Studies have shown that there is less DNA fragmentation in material carried in the head of sperms selected by this method. Less DNA fragmentation can contribute to healthy embryo development.

TESA / microTESE / MESA

Cases, when no sperm cells are detected in a semen sample, are known as azoospermia. To simplify, we can divide azoospermia cases into two groups.

Obstructive azoospermia: Sperm cells produced in testicles cannot get mixed into the semen and thus do not come out due to blockages in the channels that normally carry and deliver sperm to the tip of a penis. Therefore, no sperm cells are found in sperm analyses in these patients. There are basically no problems with sperm production. But there is a disorder that prevents the sperm cells from mixing with semen.
Non-obstructive azoospermia: The principal disorder is the production of sperm in testicles. There are no issues with the carrying channels. Cases of late-diagnosed undescended testicles, mumps infections, varicocellular disorders, cancer treatments, and genetic disorders are the most common causes.

Several types of operations allow us to find sperm in cases when no sperm is found in the semen sample. The most frequently used operations are:

TESA (Testicular Sperm Aspiration): this procedure is usually performed under local anesthetic or sedation. No surgical incisions are made. Experienced urologist using a needle enters testicles unguided and attempts to aspirate sperm using an injector and applying negative pressure. It is the most commonly used method in patients with obstructive azoospermia.
MicroTESE (microscopic testicular sperm extraction): this procedure is performed under general anesthesia. In some rare cases, local anesthetics may also be used due to the patient's systemic diseases (asthma, COPD, or previous severe allergic reactions to anesthetic). An experienced urologist makes an incision and exposes the tissue found in testicles. For men with very limited sperm production, only microscopic areas of mature sperm may be present in the testis, this is the reason this procedure is performed under a special surgical microscope, that allows urologists to examine the tissue and remove only the small parts that may contain tubules with sperm cells. Once the tissue is removed it is examined in real-time by an embryologist under a microscope to look for sperm. Both testicles are thoroughly examined until the sperm cells are found. In unobstructive azoospermia cases probability of finding sperm using the microTESE procedure is 50%. All stitches that are used to close the incisions dissolve on their own. The patient is able to go home the day of the procedure.
MESA (microsurgical epididymal sperm aspiration): is another sperm aspiration procedure performed under local or general anesthesia. There are channels in the testis called epididymal tubules that the surgeon may access through tiny incisions in the scrotum area. Sperm cells gain motility and mature in these tubules, so the sperm cells found in these tubules are aspirated by the special needles may give a higher chance of success.

Once the sperm is received, the sperm cells are treated by embryologists and injected into women's eggs using the ICSI microinjection method. If a good-quality embryo develops, we transfer the embryos into the uterus and wait for the implantation.

Egg (Oocyte) freezing

Egg freezing is a method of preserving a woman's eggs (oocytes) so she can try and have children at a later date. It’s important to understand that freezing the eggs does not guarantee a future pregnancy. Egg freezing treatment may be recommended to two main groups:

1. Medically necessary:

Where we know that the patient is likely to experience fertility issues (endometriosis, diminished ovarian reserve, or a family history such as a mother who went through menopause early in life). Endometriosis is present in about 20% of women of fertility age. Endometriosis cysts that develop in ovaries are called endometrioma, or "chocolate cysts." These cysts reduce the number of healthy eggs in the ovaries. Many of the women who experience such cysts may be required to undergo repeated surgeries for reasons such as chronic pain, pain during intercourse, and pain during menstrual periods. Every such surgery may cause a significant decrease in ovarian reserve. In such cases, freezing eggs, especially before any such operation, is an important step toward fertility preservation.

2. Elective:

For various reasons such as intense work tempo, careers, or some other personal decisions, women may choose to have children later in life. At the same time, we know that fertility potential begins to decline faster in women after the age of 35, and after 40 both the number of eggs and the quality of eggs are decreasing rapidly. Our female patients who are not planning to have children immediately, but are also approaching certain age can secure their future fertility through egg freezing treatment. It is recommended to freeze 10 to 15 eggs for women under 35 and 15-20 eggs for women aged over 35 to ensure a high future pregnancy success.

Preimplantation genetic testing (PGT)

Preimplantation genetic testing allows us to examine the chromosomes of embryos obtained through IVF before transferring them back into the maternal womb. Embryos obtained through IVF treatment are expected to reach the blastocyst stage on day 5 or 6. Thanks to the development of science and technologies embryologists using special tools can now safely biopsy embryos that developed to this stage and have a good exterior appearance, after this biopsy embryos are frozen. Laboratory equipment and embryologists’ experience are crucial at this stage. Cells obtained during the biopsy are then sent to the genetics laboratory. Genetic sequencing of embryos is reported back by the laboratory between 10 and 15 days later. Embryo, which is confirmed to be genetically normal, is transferred into the womb in the following months. We may recommend this method to:

Couples with advanced maternal age (> 37 years),
Couples with recurrent IVF failures,
Couples with recurrent pregnancy loss,
Couples with familial hereditary genetic diseases (Cystic Fibrosis, Thalassemia, SMA, etc).

The main purpose of preimplantation genetic testing is to study the chromosome structure of the embryos, where normal would be 22 pairs of autosomes (body chromosomes) and 1 pair of allosomes (sex chromosomes: XX for females and XY for males). These pairs of chromosomes must be sequenced in order. Faulty sequencing leads to abnormalities, for example, a chromosome pair having a deficiency on one side (monosomy), or excess on one side (trisomy). The most common known chromosome disorder is 21, or Down Syndrome which is characterized by having 3 chromosomes.

This method enables chromosomally normal embryos to be selected for transfer back to the mother. Moreover, this method allows couples with familial hereditary genetic diseases to have healthy babies.

In Vitro Fertilization (IVF)

Classic IVF (In Vitro Fertilization)

ICSI

IMSI

Microchip

TESA / microTESE / MESA

Egg (Oocyte) freezing

Preimplantation genetic testing (PGT)

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